During a jury trial, the presence of a nurse–patient relationship is questioned. What kind of question is this and who would determine it?
1. Fact to be determined by the judge
2. Law to be determined by the jury
3. Law to be determined by the judge
4. Fact to be determined by the jury
4
Rationale: Judges determine law.
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A new nurse asks the difference between dementia and delirium. The best response is:
1. The cause of delirium is unknown. 2. Delirium develops over several weeks. 3. Delirium is often confused with depression in clients over the age of 60. 4. Delirium is a common occurrence in hospitalized clients over the age of 60.
Mr. Reynolds is admitted through the emergency department after being involved in a motor vehicle accident. His airbag failed to deploy, and he was hit in the abdomen with the steering wheel. He has an IV of 0
9% NS @ 100 mL/hr, BP 92/58, and complains of weakness, fatigue, and abdominal pain. On assessment, the nurse discovers that Mr. Reynolds is nauseated and just vomited 560 mL. The nurse is quite busy and decides to delegate client care activities to the nursing assistant. Of the following activities, which should the nurse keep? A) Taking and recording vital signs every 15 minutes B) Recording accurate intake and output C) Obtaining a baseline weight to guide therapy D) Increasing the IV rate to 250 mL/hr if the blood pressure drops to 85/50
A client's urinalysis results show a protein level of 1.8 mg/dL. Which action by the nurse is best?
a. Inform the health care provider. b. Ask the client about his or her protein in-take. c. Obtain the client's weight. d. Document the finding in the chart.
The nurse is assisting a patient with self-care needs. The theory that this nurse is most likely implementing would be:
a. Dembo's disability theory c. Piaget's social learn-ing theory b. Maslow's motiva-tional theory d. Orem's theory of self-care deficit